Assessment of the cardiovascular system is one of the most complex and nuanced skills in the EMT’s repertoire, requiring a delicate blend of physical exam techniques, focused history questions and technologically derived data. A comprehensive assessment of the cardiovascular system is neither practical nor productive in the prehospital arena, but with an appropriate focused assessment, EMS providers can readily identify most cardiovascular emergencies. This article will focus on medical causes of cardiovascular instability.
A 64-year-old woman calls 9-1-1 complaining of food poisoning. EMTs find her sitting in a chair and retching into a wastebasket. She is pale and diaphoretic and appears acutely ill. She says she came home after dining out two hours ago and suddenly felt profoundly weak and nauseous. She denies chest pain or dyspnea, but reports a mild epigastric pain that she attributes to vomiting. She has non-insulin-dependent diabetes, hypertension and high cholesterol. She has no known drug allergies, and her only meds are lisinopril, Zocor and Actos.
Vital signs are:
- Heart rate 40, with irregular, palpable radial pulses
- Respirations 20 per minute, non-labored
- BP 108/56
- SpO2 98% on room air
- ECG rhythm sinus bradycardia, with occasional ventricular escape beats CBG 154 milligrams per deciliter
Having ruled out hypoglycemia, the medics suspect other possible causes of her symptoms, begin a focused assessment and obtain a 12-lead ECG.
Finding no immediate life threats, they move on to a history and physical examination, focusing on her chief complaint and associated signs and symptoms. The traditional format of OPQRST works well for assessment of cardiac problems:
Onset: What was the patient doing when the symptoms began? Symptoms occurring at rest indicate MI, while exertional symptoms point to angina; however, do not rule out MI based on the presence of exertional angina.
Provocation/Palliation: What makes the symptoms worse or better? Symptoms relieved by rest and nitroglycerin tend to indicate stable angina, while MI pain tends to persist despite these things. If dyspnea worsens when supine, a condition known as orthopnea, CHF may exist. If chest pain eases while leaning forward, this is a hallmark sign of pericarditis and can be confirmed by global ST-segment elevation on the 12-lead ECG.
Quality: Have the patient describe the symptoms in her own words. The pain of an MI is visceral pain that is often described as a vague heaviness, pressure or tightness. Somatic, musculoskeletal pain worsens with movement and can often be reproduced by palpation. Pleuritic pain often worsens with coughing or deep inspiration, is an example of parietal pain that occurs in the body cavity linings richly innervated with sensory fibers, and is usually described as “sharp” or “stabbing” and defined in one part of the body.
The presence of pleuritic pain does not rule out MI. As many as 15% of MI patients, particularly women, present with pleuritic chest pain.
Radiation: Visceral organs share sensory nerve roots, so ischemic chest pain may radiate to other areas of the body, particularly the left arm, shoulders, jaw and neck. Since the inferior wall of the left ventricle shares sensory innervations with the diaphragm, patients experiencing inferior wall MI often present with epigastric pain, indigestion or, in rare instances, hiccups.
Severity: Ask the patient to rate the pain on a 1–10 scale. Pain measurement is purely subjective but provides a baseline for measuring the effectiveness of nitroglycerin or morphine.
Time: Ask the patient when symptoms began. MI patients commonly deny the possibility of a heart attack and delay seeking help.